Allergic Rhinitis

Medical Record 3:

Patient Information

• Name: [Patient's Name]
• Date of Birth: [Patient's DOB]
• Sex: Female
• Medical Record Number: [MRN]

-Date of Service: 04-07-2024

Sample Name: Allergic Rhinitis

Description: A 23-year-old white female presents with complaints of allergies.

Subjective: The patient reports experiencing allergies, which she believes have worsened since moving to her current location. She has a history of using Claritin and Zyrtec, both of which provided temporary relief before losing effectiveness. She also tried Allegra last summer and resumed it two weeks ago, but it does not seem to be effective. She has not used prescription nasal sprays but has tried over-the-counter sprays. She has asthma but does not require daily medication and does not believe it is currently flaring up.

Medications: The patient is currently taking Ortho Tri-Cyclen and Allegra.

Allergies: She has no known medicine allergies.

Objective

• Weight: 130 pounds
• Blood pressure: 124/78
• HEENT: Throat mildly erythematous without exudate, nasal mucosa erythematous and swollen with clear drainage, clear TMs
• Neck: Supple without adenopathy
• Lungs: Clear

Assessment: Allergic rhinitis

Plan

1. Switch to Zyrtec instead of Allegra. Loratadine is also considered as a cost-effective alternative due to possible lack of prescription coverage.
2. Samples of Nasonex (mometasone) two sprays in each nostril provided for three weeks. A prescription was also written.

Electronically signed by Jane Smith, NP. Date: 03/15/2024. Time: 10:45.